- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,479.11
| Professional | | $741.31 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,737.80 / $2,089.30
| Professional | | $1,023.29 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,380.38 / $3,162.28
| Facility | | $776.25 | $1,380.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,398.83
| Professional | | $1,000.00 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,047.13 / $1,174.90
| Professional | | $1,023.29 | $1,047.13 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,348.96 / $2,818.38
| Facility | | $776.25 | $1,348.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $575.44
| Professional | | $562.34 | $562.34 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,398.83
| Facility | | $933.25 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,318.26
| Professional | | $676.08 | $870.96 | $1,318.26 |